While performing an assessment, the nurse presses the client's arm with the tip of her thumb, holds for a few seconds, and releases. The nurse observes the client as shown. What is the nurse assessing?
Pitting edema
Capillary refill
Skin temperature
Peripheral pulses
The Correct Answer is A
A. Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.
B. Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.
C. Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.
D. Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Smoking: Although smoking is a risk factor for cardiovascular diseases and can contribute to thrombosis, it is not the most immediate factor in the context of post-surgical immobility.
B. Hypertension: While hypertension is a significant cardiovascular risk factor, it is less directly related to deep vein thrombosis compared to immobility.
C. Obesity: Obesity can increase the risk of DVT, but immobility, especially after surgery, is a more direct and immediate contributing factor.
D. Immobility: Immobility is a critical factor in the development of deep vein thrombosis, particularly in postoperative clients who may be bedridden or have limited mobility.
Correct Answer is D
Explanation
A. A flat murmur does not accurately describe the type of murmur associated with mitral insufficiency.
B. Mitral insufficiency is typically classified as a systolic murmur, not diastolic.
C. An absent murmur would indicate no audible sound, which is not applicable here.
D. Mitral insufficiency or regurgitation is characterized by a systolic murmur due to the backflow of blood from the left ventricle into the left atrium during systole.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.